Tim Nowak, AAS, BS, NRP, CCEMTP, SPO, MPO, CADS
Application of an EtCO2 sampling device and waveform monitoring, especially during bag-valve mask ventilation, is well within the capability of EMTs
Should EMTs be trained and required to utilize capnography within their scope of practice and clinical care?
That was a short article!
If you can administer bronchodilators via nebulizer, provide positive pressure via CPAP or insert a supraglottic airway device to create a secured airway, then capnography should be a part of your clinical repertoire; simple as that.
Relying solely on lung sounds and the patient’s physical presentation, should not be the end of your differential diagnosis determination. That’s right – differential diagnosis – as an EMT!
Capnography – the utilization of devices to acquire, and the interpretation of numeric and waveform data – should be both an addition and mainstay within the clinical practice of EMS providers. If you have the means to correct airway problems, then you should certainly have the tools to identify the problem.
To explore how your agency should consider incorporating capnography into EMT practice, let’s break-down some clinical applications and training points of this invaluable assessment tool – numeric end-tidal carbon dioxide (EtCO2) values obtained through a direct waveform presentation – a capnograph. Here are three scenarios your EMTs should be trained to use capnography for.
It’s not all about shark fins. A clinician needs to understand what to do when there aren’t any sharks in the water (after all, not all that wheezes is asthma, and not all that wheezes presents with shark fins). A mainstay in the clinical assessment of dyspnea is assessing (or interpreting) a capnograph. Just like a 12-lead ECG associates to chest pain, a capnograph associates to dyspnea.
Sloping upstrokes, normal box waveforms, rapid presentations and sloping downstrokes all equate to something different, and a nebulizer with a bronchodilator isn’t necessarily the correct answer for all of them. Using capnography to help determine which tool in your toolbox is most appropriate to provide patient care is an essential component toward appropriate clinical care.
Utilizing capnography to assess dyspnea is certainly more than a “technician” skill – it’s a “clinician” skill – so is determining ST-segment elevation, deciding whether epinephrine is appropriate for anaphylaxis management, and administering dextrose for hypoglycemia management.
If your patient is not breathing effectively, but is alive, then adjusting your ventilations to a more patient-centered rate – rather than a standardized once every six to eight seconds rate – can aim to bring their internal chemistry into a more normalized range. Too rapid breaths results in the greater expulsion of carbon dioxide, and that may not be result that you’re looking to achieve.
In the event that your patient isn’t breathing, capnography certainly has its place in a number of clinical settings. Connecting an in-line adapter to your bag-valve device can help you to confirm airway patency.
Is your head-tilt maneuver with mask ventilations effective? Or, is your supraglottic airway truly ventilating into the trachea and lungs, rather than the esophagus and stomach? The presence of carbon dioxide indicates gas exchange; perfusion or diffusion. Combined with a proper seal made by your mask, or a properly sized and seated supraglottic device, end-tidal assessment can provide the airway confirmation that you’re looking for – and with greater clinical reliability than the presence of lung sounds (which could be misconstrued with epigastric sounds).
Eupnea is a medical term for normal breathing. Keeping in mind that the total assessment of capnography involves more than just ventilations, there’s also a metabolic component that requires a bit more thought and attention, as well as classroom time.
In the end – whether it’s for assessing dyspnea, apnea or eupnea – integrating capnography into EMT training and scope of practice is a big step toward their clinical advancement, and these are situations where EMTs should absolutely be using it.